Multiple vector fluid localization

ABSTRACT

A differential or relative measurement between an orthogonal measurement vector and another measurement vector can be used to determine the location where fluid accumulation is occurring or the local change in such fluid accumulation. This can help diagnose or treat infection or hematoma or seroma at a pocket of an implanted cardiac rhythm management device, other implanted medical device, or prosthesis. It can also help diagnose or treat pulmonary edema, pneumonia, pulmonary congestion, pericardial effusion, pericarditis, pleural effusion, hemodilution, or another physiological condition.

CLAIM OF PRIORITY

This application is a continuation of U.S. application Ser. No.12/912,219, filed Oct. 26, 2010, which claims the benefit of priorityunder 35 U.S.C. §119(e) of Thakur et al., U.S. Provisional PatentApplication Ser. No. 61/255,360, entitled “MULTIPLE VECTOR FLUIDLOCALIZATION”, filed on Oct. 27, 2009, each of which is hereinincorporated by reference in its entirety.

BACKGROUND

Cardiac rhythm management (CRM) devices can help assist heart function,such as by providing pacing electrostimulations to evoke responsiveheart contractions, providing cardiac resynchronization therapy (CRT)electrostimulations to coordinate the spatial nature of a heartcontraction of one or more heart chambers, providing antitachyarrhythmiapacing, cardioversion, or defibrillation shocks to interrupt atachyarrhythmia, or providing neurostimulation to influence sympatheticor parasympathetic nervous system response.

Diagnosing the physiological condition of a patient can involvedetermining whether fluid accumulation has occurred. For example,congestive heart failure (CHF) patients can have poor cardiac output(CO) from the heart. This can lead to fluid buildup in the lungs (e.g.,pulmonary edema) or in the limbs (e.g., peripheral edema). Fluidaccumulation status can be monitored by monitoring tissue impedance.Tissue impedance monitoring can involve injecting a test current intothe tissue, and monitoring a resulting voltage. The resulting voltagecan provide an indication of tissue impedance. The tissue impedance canprovide an indication of how wet the tissue is. As the tissue becomeswetter, its impedance decreases.

Wang U.S. Pat. No. 7,149,573 discloses an example of tissue impedancemonitoring, including determining contributing physiological impedancefactors, such as lung resistivity, blood resistivity, heart muscleresistivity, skeletal muscle resistivity, heart volume and lung volume.(See Wang '573 at Abstract.) Wang's impedance determination apparentlyrelies upon parallel vectors—Wang's test current is injected betweenelectrodes defining a test current vector therebetween, and theresulting voltage is measured between electrodes defining a responsevoltage vector therebetween, and the response voltage vector issubstantially parallel in direction to the test current vector. (See,e.g., Wang '573 at col. 9, lines 30-60.)

OVERVIEW

The present inventors have recognized, among other things, thatdetermining using a parallel vector approach to determine fluidaccumulation can provide only limited sensitivity, which can make itmore difficult to determine whether fluid accumulation is present, thedegree to which fluid accumulation is present, whether the fluidaccumulation is increasing or decreasing, or the particular localizedregion experiencing the fluid accumulation. The present inventors havealso recognized, among other things, that localizing the particularregion experiencing the fluid accumulation can be a helpful diagnostic.For example, the present inventors have recognized that discriminatingbetween different regions to determine which region is experiencingfluid accumulation, which region is experiencing more (or less) fluidaccumulation, or the relative degree of fluid accumulation or change influid accumulation between the regions, can provide helpful diagnosticinformation to a physician or an automated medical device, allowingtherapy to be selected or adjusted accordingly. The present inventorshave recognized that this, in turn, can enhance patient care, such as ofCHF or other patients.

The present inventors have also recognized, among other things, thatusing (1) an orthogonal measurement vector and (2) a non-orthogonalmeasurement vector, a relative measurement between (1) and (2) can beused to provide a more sensitive indication of fluid accumulation. Anorthogonal measurement vector can be conceptualized as including anexcitation vector defined by excitation electrodes that are used toprovide the excitation signal, and a response vector defined by responseelectrodes that are used to sense a response to the excitation signal,wherein the response vector is substantially orthogonal to theexcitation vector. The present inventors have further recognized thatthis more sensitive relative measurement can be used to localize aregion of fluid accumulation, or to distinguish between differentregions of fluid accumulation. As illustrative examples, this can beuseful to diagnose, or to discriminate between:

-   -   fluid accumulation localized at a “pocket” or like region at        which an implantable CRM device or other implantable medical        device (IMD) or prosthesis is located, such as can result from        infection, hematoma, or seroma;    -   fluid accumulation localized in the lungs, such as can result        from pulmonary edema, pneumonia, or pulmonary congestion;    -   global fluid accumulation (e.g., in the lungs and elsewhere),        such as can result from an acute decompensation episode as        sometimes experienced by a CHF patient;    -   fluid accumulation around the heart (e.g., pericardial effusion,        during the early stages of which fluid accumulation occurs in        the pericardial sac around the heart such as near the apex of        the heart); or    -   hemodilution, which constitutes a decreased concentration of        cells and solids in the blood resulting from gain of fluid.

Example 1 can include subject matter that can include a first interface,configured to be coupled to implantable first electrodes configured todefine a first measurement vector, within a subject, comprising a firstexcitation vector for providing a first excitation signal and a firstresponse vector for sensing a first response to the first excitationsignal. A second interface can be configured to be coupled toimplantable second electrodes configured to define a second measurementvector, within the subject, comprising a second excitation vector forproviding a second excitation signal and a second response vector forsensing a second response to the second excitation signal, wherein thesecond excitation vector is substantially orthogonal to the secondresponse vector. A tissue characteristic measurement circuit,selectively communicatively coupled to the first and second electrodes,and configured to repeatedly perform a first tissue characteristicmeasurement using the first measurement vector and to perform a secondtissue characteristic measurement using the second measurement vector. Aprocessor can be communicatively coupled to the tissue characteristicmeasurement circuit, the processor configured to use information about achange in the first tissue characteristic measurement over a period oftime and information about a change in the second tissue characteristicmeasurement over the period of time to provide an indication associatedwith how much fluid is present at an first location in the subjectrelative to how much fluid is present at a second location in thesubject.

In Example 2, the subject matter of Example 1 can optionally furtherinclude the implantable first electrodes and the implantable secondelectrodes.

In Example 3, the subject matter of any one of Examples 1-2 canoptionally include the processor being configured to use the informationabout the change in the first tissue characteristic measurement over theperiod of time and the information about the change in the second tissuecharacteristic measurement over the period of time to provide anindication associated with how much fluid is present at the firstlocation, wherein the first location is associated with a pocket aboutan implantable medical device, relative to how much fluid is present atthe second location, wherein the second location is within the subjectbut separated from the pocket about the implantable medical device.

In Example 4, the subject matter of any one of Examples 1-3 canoptionally include the processor being configured to use the informationabout the change in the first tissue characteristic measurement over theperiod of time and the information about the change in the second tissuecharacteristic measurement over the period of time to provide anindication of whether infection is present at the first locationassociated with the pocket about the implantable medical device.

In Example 5, the subject matter of any one of Examples 1-4 canoptionally include a first temperature sensor configured to beassociated with the subject, and wherein the processor is configured tobe communicatively coupled to the first temperature sensor to receiveinformation about a first temperature at a location of the subjectassociated with the first temperature sensor, and to use the informationabout the first temperature to provide the indication of whetherinfection is present at the first location associated with the pocketabout the implantable medical device.

In Example 6, the subject matter of any one of Examples 1-5 canoptionally include a second temperature sensor configured to beassociated with the subject at a different location than the firsttemperature sensor, and wherein the processor is configured to becommunicatively coupled to the second temperature sensor to receiveinformation about a second temperature at a location of the subjectassociated with the second temperature sensor, and to use theinformation about a difference between the second temperature and thefirst temperature to provide the indication of whether infection ispresent at the first location associated with the pocket about theimplantable medical device.

In Example 7, the subject matter of any one of Examples 1-6 canoptionally include the second measurement vector including a secondexcitation vector for providing a second excitation signal between aleft ventricular electrode configured to be associated with a leftventricle and a pectoral electrode configured to be associated with apectoral region, and a second response vector for sensing a secondresponse to the second excitation signal between a left ventricularelectrode configured to be associated with a left ventricle and a rightatrial electrode configured to be associated with a right atrium,wherein the second excitation vector is substantially orthogonal to thesecond response vector.

In Example 8, the subject matter of any one of Examples 1-7 canoptionally include at least one of: (a) the first measurement vectorcomprising a first excitation vector for providing a first excitationsignal between a right ventricular electrode configured to be associatedwith a right ventricle and a pectoral electrode configured to beassociated with a pectoral region, and a first response vector forsensing a first response to the first excitation signal, the sensing thefirst response using a right ventricular electrode configured to beassociated with a right ventricle and a pectoral electrode configured tobe associated with a pectoral region; (b) the first measurement vectorcomprising a first excitation vector for providing a first excitationsignal between a right atrial electrode configured to be associated witha right atrium and a pectoral electrode configured to be associated witha pectoral region, and a first response vector for sensing a firstresponse to the first excitation signal, the sensing the first responseusing a right atrial electrode configured to be associated with a rightatrium and a pectoral electrode configured to be associated with apectoral region; or (c) the first measurement vector comprising a firstexcitation vector for providing a first excitation signal between a leftventricular electrode configured to be associated with a left ventricleand a pectoral electrode configured to be associated with a pectoralregion, and a first response vector for sensing a first response to thefirst excitation signal, the sensing the first response using a leftventricular electrode configured to be associated with a left ventricleand a pectoral electrode configured to be associated with a pectoralregion.

In Example 9, the subject matter of any one of Examples 1-8 canoptionally include the processor being configured to use the informationabout the change in the first tissue characteristic measurement over theperiod of time and the information about the change in the second tissuecharacteristic measurement over the period of time to provide anindication associated with how much fluid is present at the firstlocation, wherein the first location is associated with a localized lungregion, relative to how much fluid is present at the second location,wherein the second location is within the subject and associated with aglobal region that extends beyond the localized lung region.

Example 10 can include, or can optionally be combined with any one ofExamples 1-9 to include subject matter that can include: providing afirst measurement vector, within a subject, comprising a firstexcitation vector for providing a first excitation signal and a firstresponse vector for sensing a first response to the first excitationsignal; providing a second measurement vector, within the subject,comprising a second excitation vector for providing a second excitationsignal and a second response vector for sensing a second response to thesecond excitation signal, wherein the second excitation vector issubstantially orthogonal to the second response vector; repeatedlyperforming a first tissue characteristic measurement using the firstmeasurement vector and to perform a second tissue characteristicmeasurement using the second measurement vector, and using informationabout a change in the first tissue characteristic measurement over aperiod of time and information about a change in the second tissuecharacteristic measurement over the period of time to provide anindication associated with how much fluid is present at an firstlocation in the subject relative to how much fluid is present at asecond location in the subject.

In Example 11, the subject matter of any one of Examples 1-10 canoptionally further comprise providing implantable first electrodesconfigured for providing the first, measurement vector and providingimplantable second electrodes configured for providing the secondmeasurement vector.

In Example 12, the subject matter of any one of Examples 1-11 canoptionally comprise using the information about the change in the firsttissue characteristic measurement over the period of time and theinformation about the change in the second tissue characteristicmeasurement over the period of time to provide an indication associatedwith how much fluid is present at the first location, wherein the firstlocation is associated with a pocket about an implantable medicaldevice, relative to how much fluid is present at the second location,wherein the second location is within the subject but separated from thepocket about the implantable medical device.

In Example 13, the subject matter of any one of Examples 1-12 canoptionally comprise using the information about the change in the firsttissue characteristic measurement over the period of time and theinformation about the change in the second tissue characteristicmeasurement over the period of time to provide an indication of whetherinfection is present at the first location associated with the pocketabout the implantable medical device.

In Example 14, the subject matter of any one of Examples 1-13 canoptionally comprise using information about a first temperature at alocation of the subject to provide the indication of whether infectionis present at the first location associated with the pocket about theimplantable medical device.

In Example 15, the subject matter of any one of Examples 1-14 canoptionally comprise using information about a second temperature at alocation of the subject that is different from the location associatedwith the first temperature to provide the indication of whetherinfection is present at the first location associated with the pocketabout the implantable medical device.

In Example 16, the subject matter of any one of Examples 1-15 canoptionally include the second measurement vector comprising a secondexcitation vector for providing a second excitation signal between aleft ventricle region and a pectoral region, and a second responsevector for sensing a second response to the second excitation signalbetween a left ventricle region and a right region, wherein the secondexcitation vector is substantially orthogonal to the second responsevector.

In Example 17, the subject matter of any one of Examples 1-16 canoptionally include at least one of: (a) the first measurement vectorcomprising a first excitation vector for providing a first excitationsignal between a right ventricular region and a pectoral region, and afirst response vector for sensing a first response to the firstexcitation signal, the sensing the first response between a rightventricular region and a pectoral region; (b) the first measurementvector comprising a first excitation vector for providing a firstexcitation signal between a right atrial region and a pectoral region,and a first response vector for sensing a first response to the firstexcitation signal, the sensing the first response between a right atrialregion and a pectoral region; or (c) the first measurement vectorcomprising a first excitation vector for providing a first excitationsignal between a left ventricular region and a pectoral region, and afirst response vector for sensing a first response to the firstexcitation signal, the sensing the first response between a leftventricular region and a pectoral region.

In Example 18, the subject matter of any one of Examples 1-17 canoptionally comprise using the information about the change in the firsttissue characteristic measurement over the period of time and theinformation about the change in the second tissue characteristicmeasurement over the period of time to provide an indication associatedwith how much fluid is present at the first location, wherein the firstlocation is associated with a localized lung region, relative to howmuch fluid is present at the second location, wherein the secondlocation is within the subject and associated with a global region thatextends beyond the localized lung region.

Example 19 can include, or can be combined with the subject matter ofany one of Examples 1-18 to include subject matter including means forproviding a first measurement vector, within a subject, comprising afirst excitation vector for providing a first excitation signal and afirst response vector for sensing a first response to the firstexcitation signal; means for providing a second measurement vector,within the subject, comprising a second excitation vector for providinga second excitation signal and a second response vector for sensing asecond response to the second excitation signal, wherein the secondexcitation vector is substantially orthogonal to the second responsevector; means for repeatedly performing a first tissue characteristicmeasurement using the first measurement vector and to perform a secondtissue characteristic measurement using the second measurement vector;and means for using information about a change in the first tissuecharacteristic measurement over a period of time and information about achange in the second tissue characteristic measurement over the periodof time to provide an indication associated with how much fluid ispresent at an first location in the subject relative to how much fluidis present at a second location in the subject.

In Example 20, the subject matter of any one of Examples 1-19 canoptionally comprise a processor configured to use the information aboutthe change in the first tissue characteristic measurement over theperiod of time and the information about the change in the second tissuecharacteristic measurement over the period of time to provide anindication associated with how much fluid is present at the firstlocation, wherein the first location is associated with a pocket aboutan implantable medical device, relative to how much fluid is present atthe second location, wherein the second location is within the subjectbut separated from the pocket about the implantable medical device. Theprocessor can be configured to use the information about the change inthe first tissue characteristic measurement over the period of time andthe information about the change in the second tissue characteristicmeasurement over the period of time to provide an indication of whetherinfection is present at the first location associated with the pocketabout the implantable medical device.

The examples can be combined with each other or with the other subjectmatter described herein in any combination or permutation. This overviewis intended to provide an overview of subject matter of the presentpatent application. It is not intended to provide an exclusive orexhaustive explanation of the invention. The detailed description isincluded to provide further information about the present patentapplication.

BRIEF DESCRIPTION OF THE DRAWINGS

In the drawings, which are not necessarily drawn to scale, like numeralsmay describe similar components in different views. Like numerals havingdifferent letter suffixes may represent different instances of similarcomponents. The drawings illustrate generally, by way of example, butnot by way of limitation, various embodiments discussed in the presentdocument.

FIG. 1 shows an example of an implantable or other ambulatory cardiacrhythm management (CRM) device.

FIG. 2 shows an example of portions of the CRM device electronics unit.

FIG. 3 is a graph illustrating examples of experimentally-observed dataof the fractional change in impedance observed before and afterinjecting saline fluid into a pocket into which a CRM device electronicsunit was implanted, with the graph illustrating four different impedancevector configurations that were used.

FIG. 4 is a graph illustrating experimental data indicating a fractionalchange in impedance resulting from lung fluid accumulation for the samefour vectors as FIG. 3.

FIG. 5 shows an example of a technique to determine whether fluidaccumulation is present and, if so, whether such fluid accumulation islocal to a pocket in which a CRM device electronics unit is implanted,which can be indicative of local pocket infection, hematoma or seroma,or the like.

FIG. 6 shows an example of a technique to determine whether fluidaccumulation is present and, if so, whether such fluid accumulation islocal to a lung region or indicative of a more global fluid overloadcondition.

DETAILED DESCRIPTION

The present inventors have recognized that using (1) an orthogonalmeasurement vector and (2) a non-orthogonal measurement vector, arelative measurement between (1) and (2) can be used to provide a moresensitive indication of fluid accumulation, such as to localize a regionof fluid accumulation, or to distinguish between different regions offluid accumulation.

FIG. 1 shows an example of an implantable or other ambulatory cardiacrhythm management (CRM) device 100. In an example, the CRM device 100can include an electronics unit 102 that can include ahermetically-sealed biocompatible housing 104 and a header 106 extendingtherefrom. The housing 104 can carry a power source and electronics. Theheader 106 can include one or more receptacles, such as for receivingthe proximal ends of intravascular leads 108A-C. In an example, the lead108A can be an intravascular RV lead that can extend from the superiorvena cava (SVC) into the right atrium (RA), and then into the rightventricle (RV). The lead 108A can include an RV apical tip electrode110, a slightly more proximal RV ring electrode 112, a still slightlymore proximal RV shock coil electrode 114, and an even more proximal RAor SVC shock coil electrode 116. The various electrodes can be used fordelivering electrical energy or sensing intrinsic electrical heartsignals. An intravascular CS/LV lead 108B can extend from the SVC intothe RA, through a coronary sinus (CS) into the coronary vasculature,such as near a portion of a left ventricle (LV). In an example, thissecond CS/LV lead 108B can include a distal electrode 118 and a proximalelectrode 120, from which electrostimulation energies can be deliveredor intrinsic electrical heart signals can be sensed. An intravascularright atrial (RA) lead 108C can extend from the SVC into the RA, and caninclude a distal electrode 119 and a proximal electrode 121. Otherelectrodes (e.g., a housing electrode 105 on the housing 104, a headerelectrode 107 on the header 106, an epicardial electrode, a subcutaneouselectrode located away from the heart, or an electrode locatedelsewhere) or leads can be used.

In an example, an implantable CRM device 100 can include a communicationcircuit, such as to wireless communicate unidirectionally orbidirectionally with an external local interface 121, such as a CRMdevice programmer, repeater, handheld device, or the like. The localinterface 121 can be configured to communicate via a wired or wirelesscomputer or communication network 122 to a remote interface 124, such asa remote computer or server or the like.

FIG. 2 shows an example of portions of the CRM device electronics unit102. In an example, this can include a switching circuit 200, such asfor selectively connecting to the various electrodes such as on theleads 108A-B or elsewhere. A sensing circuit 202 can be selectivelycoupled to various electrodes by the switching circuit 200, and caninclude sense amplifiers, filter circuits, other circuits such as forsensing intrinsic electrical signals, such as intrinsic heart signals. Atherapy circuit 204 can be selectively coupled to various electrodes bythe switching circuit 200, and can include therapy energy generationcircuitry (e.g., capacitive, inductive, or other) such as forgenerating, storing, or delivering an electrostimulation, cardioversion,defibrillation, or other energy. An impedance measurement circuit 206can be selectively coupled to various electrodes by the switchingcircuit 200, such as for measuring a lead impedance, a tissue impedance,a regional or organ impedance, or other impedance. In an example, thesensing circuit 202, the therapy circuit 204, or the impedance circuit206 can be coupled to a processor circuit 208. In an example, theprocessor 208 can perform instructions, such as for signal processing ofsignals derived by the sensing circuit 202 or the impedance circuit 206,or for controlling operation of the therapy circuit 204 or otheroperations of the CRM device 100. The processor 208 can also be coupledto or include a memory circuit 210, such as for storing or retrievinginstructions or data, or a communication circuit 212, such as forcommunicating with the local interface 121.

FIG. 3 is a graph illustrating examples of experimentally-observed dataof the fractional change in impedance observed before and afterinjecting saline fluid into a pocket into which a CRM device electronicsunit 102 was implanted, with the graph illustrating four differentimpedance vector configurations that were used. Such injection of salineinto the pocket is believed to be at least somewhat representative ofconditions that would be observed if the pocket became infected, leadingto localized fluid accumulation in the pocket. The example of FIG. 3shows impedance determined from: (1) an RV-Can (non-orthogonal)electrode configuration, in which both the excitation vector and theresponse vector are provided between an RV electrode (e.g., 110, 112, or114) and a Can electrode (e.g., 107 or 106); (2) an RA-Can(non-orthogonal) electrode configuration, in which both the excitationand the response vector are provided between an RA electrode (e.g., 119or 121) and a Can electrode (e.g., 107 or 106); (3) an LV-Can(non-orthogonal) electrode configuration, in which both the excitationand the response vector are provided between an CS/LV electrode (e.g.,118 or 120) and a Can electrode (e.g., 107 or 106); and (4) an RA-LV-Can(orthogonal) electrode configuration, in which the excitation vector isprovided between a CS/LV electrode (e.g., 118 or 120) and a Canelectrode (e.g., 107 or 106) and the response vector is provided betweena CS/LV electrode (e.g., 118 or 120) and an RA electrode (e.g., 119 or121).

In this example, the three non-orthogonal vectors exhibited a fractionalimpedance change of about 15%. The orthogonal vector exhibited afractional impedance change of about 10%. Thus, the orthogonal vectorwas observed to be less sensitive to fluid accumulation around thepocket than the non-orthogonal vectors. The present inventors haverecognized, among other things, that because of this relativedifference, an orthogonal vector can be used together with anon-orthogonal vector to determine whether fluid accumulation islocalized to the pocket or otherwise, as explained further below.

FIG. 4 is a graph illustrating experimental data indicating a fractionalchange in impedance resulting from lung fluid accumulation for the samefour vectors as FIG. 3. Unlike the case of FIG. 3 for pocket fluidaccumulation, the orthogonal vector exhibited a greater fractionalchange in impedance (about 13%) than the non-orthogonal vectors (about2% to about 7%). Thus, as can be seen in FIG. 4, the orthogonal vectorwas observed to be more sensitive to pulmonary fluid accumulation thanthe non-orthogonal vectors. The present inventors have recognized, amongother things, that because of this relative difference, an orthogonalvector can be used together with a non-orthogonal vector to determinewhether fluid accumulation is localized to the lungs or otherwise, asexplained further below.

FIG. 5 shows an example of a technique to determine whether fluidaccumulation is present and, if so, whether such fluid accumulation islocal to a pocket in which a CRM device electronics unit 102 isimplanted, which can be indicative of local pocket infection, hematomaor seroma, or the like. Infection rates are believed to be increasingfaster than CRM device implant rates. Infection can result in deviceremoval, antibiotic treatment, or both, and can be very costly. In anexample, the technique of FIG. 5 can be performed all or in part byusing the CRM device 100 shown in FIG. 1.

At 502, a non-orthogonal first measurement vector and an orthogonalsecond vector can be monitored (e.g., trended over an acute or chronicperiod of time). As illustrative examples, the non-orthogonal firstmeasurement vector can include RV-Can, RA-Can, or LV-Can, and theorthogonal second measurement vector can include RA-LV-Can, someexamples of such non-orthogonal and orthogonal measurement vectors aredescribed above. The monitoring can include providing an excitationsignal and measuring a response signal, such as to measure a tissuecharacteristic. In an example, the monitoring can include providing anexcitation current of specified amplitude, and measuring a voltageresponse thereto, such as to provide an indication of tissue impedance.

At 504, it is determined whether a tissue characteristic meets athreshold. In an example, this can include detecting when a tissueimpedance falls below a threshold value, indicating the presence offluid accumulation. The threshold value need not be static or absolute,but can vary or be relative, such as an offset from a baseline long termvalue, for example. Detecting whether the tissue impedance falls below athreshold value can be determined using a single measurement vector, orusing a weighted or other combination of multiple measurement vectors,such as non-orthogonal vectors, orthogonal vectors, or a combinationthereof. The comparison to a threshold can use a single measurement ormultiple measurements, such as an average or other central tendency ofmultiple measurements obtained during a specified period of time.

At 506, if it has been determined at 504 that the tissue characteristicmeets a threshold value (e.g., fluid accumulation is present), then itcan be determined at 506 whether a change in the tissue characteristicof the orthogonal vector is less than a change in the tissuecharacteristic of the non-orthogonal vector. For an example in which thetissue characteristic includes a tissue impedance, it can be determinedat 506 whether a change in tissue impedance of the orthogonal vector isless than a change in tissue impedance of the non-orthogonal vector and,if so, then at 508, the fluid accumulation is declared to be associatedwith local fluid in the pocket, and otherwise, at 510, the fluidaccumulation is declared to not be associated with local fluid in thepocket, but instead associated with fluid elsewhere (e.g., global fluidoverload, pulmonary edema, etc.). Local fluid in the pocket can be asign of pocket infection, hematoma, or seroma. Information about (orbased on) whether the fluid accumulation is local to the pocket (e.g.,fluid presence, fractional change in impedance, indication of infection,hematoma, or seroma, etc.) can be communicated to a user or automatedprocess, such as to provide a diagnostic indication or for use incontrolling a therapy provided by the CRM device 100, another implanted,ambulatory, or other medical device, or by a physician or othercaregiver. Such communication can be internal to the electronics unit102 of the CRM device 100, or can involve communication with the localinterface 121 or with the remote interface 124. The acts described inFIG. 5 can be performed by the processor 208 or other circuitry in theelectronics unit 102 of the CRM device 100, or by a processor or othercircuitry associated with the local interface 121 or the remoteinterface 124, or using some combination of the CRM device 100, thelocal interface 121, or the remote interface 124.

At 506, determining whether a change in the tissue characteristic of anorthogonal vector is less than a change in the tissue characteristic ofthe non-orthogonal vector need not involve comparing absolute actualchanges in the tissue characteristic. For example, where the tissuecharacteristic includes a tissue impedance, it can involve comparing afractional change in the impedance of the orthogonal vector to afractional change in the impedance of the non-orthogonal vector or caninvolve scaling the impedance of the non-orthogonal vector or theorthogonal vector.

As an illustrative example, the comparison can be expressed as:

ΔZ _(O) /Z _(O) <α·ΔZ _(NO) /Z _(NO)

where, in the above equation, ΔZ_(O) represents the change in impedanceof the orthogonal vector, Z_(O) represents a baseline (e.g., long term)value of the impedance of the orthogonal vector, ΔZ_(O)/Z_(O) representsa fractional change in impedance of the orthogonal vector relative toits baseline value, ΔZ_(NO) represents the change in impedance of thenon-orthogonal vector, Z_(NO) represents a baseline (e.g., long term)value of the impedance of the non-orthogonal vector, ΔZ_(NO)/Z_(NO)represents a fractional change in impedance of the non-orthogonal vectorrelative to its baseline value, and α represents a specified scalingfactor for the comparison to be applied to a specified side of therelationship of the above comparison. This example is merelyillustrative of the type of comparison that can be made. Othercomparisons, or variations on the above comparison can be made. Forexample, where the decrease in fluid impedance is expected to exhibit aslower time-course, a cumulative sum of difference (e.g., summingimpedance deviations from the baseline over a specified time period) orlike technique can be used to determine the change the non-orthogonaland orthogonal impedances.

FIG. 6 shows an example of a technique to determine whether fluidaccumulation is present and, if so, whether such fluid accumulation islocal to a lung region or indicative of a more global fluid overloadcondition. This can be useful to distinguish between pneumonia, whichcan be indicated by fluid accumulation that is local to a lung region,and global fluid overload, which can be indicative of a CHFdecompensation episode. Pneumonia is a risk factor for CHF patients andis also a relatively prevalent (e.g., 15%) comorbidity for CHF patientsbeing admitted for hospitalization. In an example, the technique of FIG.6 can be performed all or in part by using the CRM device 100 shown inFIG. 1.

At 602, a non-orthogonal first measurement vector and an orthogonalsecond vector can be monitored (e.g., trended over an acute or chronicperiod of time). In the example of FIG. 6, the non-orthogonal firstmeasurement vector can include a vector that is substantially localwithin the heart (e.g., using RV tip electrode 110 and RV Coil electrode114 for delivering an excitation and measuring the response) and theorthogonal second measurement vector can include RA-LV-Can, such asdescribed above. The monitoring can include providing an excitationsignal and measuring a response signal, such as to measure a tissuecharacteristic. In an example, the monitoring can include providing anexcitation current of specified amplitude, and measuring a voltageresponse thereto, such as to provide an indication of tissue impedance.

At 604, it is determined whether a tissue characteristic meets athreshold. In an example, this can include detecting when a tissueimpedance falls below a threshold value, indicating the presence offluid accumulation. The threshold value need not be static or absolute,but can vary or be relative, such as an offset from a baseline long termvalue, for example. Detecting whether the tissue impedance falls below athreshold value can be determined using a single measurement vector, orusing a weighted or other combination of multiple measurement vectors,such as non-orthogonal vectors, orthogonal vectors, or a combinationthereof. The comparison to a threshold can use a single measurement ormultiple measurements, such as an average or other central tendency ofmultiple measurements obtained during a specified period of time.

At 606, if it has been determined at 604 that the tissue characteristicmeets a threshold value (e.g., fluid accumulation is present), then itcan be determined at 606 whether a change in the tissue characteristicof the orthogonal vector is less than a change in the tissuecharacteristic of the non-orthogonal vector. For an example in which thetissue characteristic includes a tissue impedance, it can be determinedat 606 whether a change in tissue impedance of the orthogonal vector isless than a change in tissue impedance of the non-orthogonal vector and,if so, then at 608, the fluid accumulation is declared to be associatedwith local fluid in the lungs, and otherwise, at 610, the fluidaccumulation is declared to not be associated with local fluid in thelungs (e.g., such as can arise from pneumonia), but instead associatedwith fluid elsewhere (e.g., global fluid overload such as associatedwith a CHF decompensation episode. Information about (or based on)whether the fluid accumulation is local to the lungs (e.g., fluidpresence, fractional change in impedance, indication of pneumonia, CHFdecompensation, etc.) can be communicated to a user or automatedprocess, such as to provide a diagnostic indication or for use incontrolling a therapy provided by the CRM device 100 (e.g., cardiacresynchronization therapy (CRT)), by another implanted, ambulatory, orother medical device, or by a physician or other caregiver. Suchcommunication can be internal to the electronics unit 102 of the CRMdevice 100, or can involve communication with the local interface 121 orwith the remote interface 124. The acts described in FIG. 6 can beperformed by the processor 208 or other circuitry in the electronicsunit 102 of the CRM device 100, or by a processor or other circuitryassociated with the local interface 121 or the remote interface 124, orusing some combination of the CRM device 100, the local interface 121,or the remote interface 124.

At 606, determining whether a change in the tissue characteristic of anorthogonal vector is less than a change in the tissue characteristic ofthe non-orthogonal vector need not involve comparing absolute actualchanges in the tissue characteristic. For example, where the tissuecharacteristic includes a tissue impedance, it can involve comparing afractional change in the impedance of the orthogonal vector to afractional change in the impedance of the non-orthogonal vector or caninvolve scaling the impedance of the non-orthogonal vector or theorthogonal vector.

As an illustrative example, the comparison can be expressed as:

ΔZ _(O) /Z _(O) <α·ΔZ _(NO) /Z _(NO)

where, in the above equation, ΔZ_(O) represents the change in impedanceof the orthogonal vector, Z_(O) represents a baseline (e.g., long term)value of the impedance of the orthogonal vector, ΔZ_(O)/Z_(O) representsa fractional change in impedance of the orthogonal vector relative toits baseline value, ΔZ_(NO) represents the change in impedance of thenon-orthogonal vector, Z_(NO) represents a baseline (e.g., long term)value of the impedance of the non-orthogonal vector, ΔZ_(NO)/Z_(NO)represents a fractional change in impedance of the non-orthogonal vectorrelative to its baseline value, and a represents a specified scalingfactor for the comparison to be applied to a specified side of therelationship of the above comparison.

As described above, in the example of FIG. 6, the non-orthogonal firstmeasurement vector can include a vector that is substantially localwithin the heart (e.g., using RV tip electrode 110 and RV Coil electrode114 for delivering an excitation and measuring the response) and theorthogonal second measurement vector can include RA-LV-Can, such asdescribed above.

This example is merely illustrative of the type of comparison that canbe made. Other comparisons, or variations on the above comparison can bemade. For example, where the decrease in fluid impedance is expected toexhibit a slower time-course, a cumulative sum of difference (e.g.,summing impedance deviations from the baseline over a specified timeperiod) or like technique can be used to determine the change thenon-orthogonal and orthogonal impedances.

In an example, the techniques of FIGS. 5 and 6 can be used together. Forexample, the technique of FIG. 5 can be used to determine whether afluid accumulation is due to local fluid accumulating in the pocket orsomething else, such as described above. If something else, then thetechnique of FIG. 6 can be used to further determine whether the fluidaccumulation is due to fluid accumulating in the lungs (e.g., frompneumonia) or something else, such as a global fluid overload (e.g.,from CHF decompensation).

More generally, the examples of techniques described above with respectto FIGS. 5 and 6 can be applied more generally to detect variousconditions such as by using a differential tissue characteristic betweenan orthogonal vector and a non-orthogonal vector. Further, variousorthogonal and non-orthogonal vectors can be used together in variouspermutations and combinations. Table 1 below lists some examples.

TABLE 1 Examples of Physiological Conditions Detectable using a Non-Orthogonal Vector and an Orthogonal Vector Non-Orthogonal ConditionVector Orthogonal Vector Pocket Fluid (e.g., from LV (e.g., 118, 120)-RA (e.g., 119, 121)-LV infection, hematoma, or Can (e.g., 105, 107)(e.g., 118, 120)-Can seroma) (e.g., 105, 107) Pocket Fluid (e.g., fromLV (e.g., 118, 120)- RV (e.g., 110, 112, 114)- infection, hematoma, orCan (e.g., 105, 107) LV (e.g., 118, 120)-Can seroma) (e.g., 105, 107)Pocket Fluid (e.g., from LV (e.g., 118, 120)- SVC (e.g., 116)-LVinfection, hematoma, or Can (e.g., 105, 107) (e.g., 118, 120)-Canseroma) (e.g., 105, 107) Pocket Fluid (e.g., from LV (e.g., 118, 120)-RA (e.g., 119, 121)-Can infection, hematoma, or Can (e.g., 105, 107)(e.g., 105, 107)-LV seroma) (e.g., 118, 120) Pocket Fluid (e.g., from RV(e.g., 110, 112, RA (e.g., 119, 121)-Can infection, hematoma, or114)-Can (e.g., 105, (e.g., 105, 107)-LV seroma) 107) (e.g., 118, 120)Pocket Fluid (e.g., from RA (e.g., 119, 121)- SVC (e.g., 116)-Caninfection, hematoma, or Can (e.g., 105, 107) (e.g., 105, 107)-LV seroma)(e.g., 118, 120) Pericardial Fluid (e.g., RV (e.g., 110, 112, RA (e.g.,119, 121)-RV from pericardial 114)-LV (e.g., 118, (e.g., 110, 112,114)-LV effusion or pericarditis) 120) (e.g., 118, 120) PericardialFluid (e.g., RA (e.g., 1119, RA (e.g., 119, 121)-RV from pericardial121)-RV(e.g., 110, (e.g., 110, 112, 114)-LV effusion or pericarditis)112, 114) (e.g., 118, 120) Pericardial Fluid (e.g., RV (e.g., 110, 112,SVC (e.g., 116)-RV from pericardial 114)-LV (e.g., 118, (e.g., 110,112., 114)-LV effusion or pericarditis) 120) (e.g., 118, 120)Pericardial Fluid (e.g., SVC (e.g., 116)-RV SVC (e.g., 116)-RV frompericardial (e.g., 110, 112, 114) (e.g., 110, 112, 114)-LV effusion orpericarditis) (e.g., 118, 120) Pulmonary Fluid (e.g., LV (e.g., 118,120)- RA (e.g., 119, 121)-LV from pneumonia or Can (e.g., 105, 107)(e.g., 118, 120)-Can pulmonary congestion) (e.g., 105, 107) PulmonaryFluid (e.g., RA (e.g., 119, 121)- RA (e.g., 119, 121)-LV from pneumoniaor Can (e.g., 105, 107) (e.g., 118, 120)-Can pulmonary congestion)(e.g., 105, 107) Pulmonary Fluid (e.g., RV (e.g., 110, 112, RA (e.g.,119, 121)-LV from pneumonia or 114)-Can (e.g., 105, (e.g., 118, 120)-Canpulmonary congestion) 107) (e.g., 105, 107) Hemodilution RV (e.g., 110,112, RA (e.g., 119, 121)-RV 114)-Can (e.g., 105, (e.g., 110, 112,114)-Can 107) (e.g., 105, 107) Hemodilution RA (e.g., 119, 121)- RV(e.g., 110, 112, 114)- Can(e.g., 105, 107) RA (e.g., 119, 121)-Can(e.g., 105, 107)In Table 1, the orthogonal vectors use a measurement vector comprisingan excitation vector that is different than the response vector. For atripolar orthogonal vector, the configuration can be denoted (x-y-z),such as written in the examples of Table 1, where the excitation signalis provided between the electrodes y and z and the response signal ismeasured between electrodes x and y. In a vice-versa example, theexcitation signal can be provided between the electrodes x and y and theresponse signal can be measured between the electrodes y and z.

In the above examples, the orthogonal and non-orthogonal vectors havebeen explained, for illustrative clarity, with respect to the case inwhich the electronics unit 102 of the CRM device 100 is implanted in apocket in the left pectoral region of the subject. However, this is notalways the case. In other examples, the electronics unit 102 of the CRMdevice 100 can be implanted in a pocket in the right pectoral region, orabdominally, and the orthogonal vectors and non-orthogonal vectors canbe adjusted accordingly for such different implant locations of theelectronics unit 102 of the CRM device 100.

In an example, for a left-side pectorally implanted electronics unit 102of the CRM device 100, examples of orthogonal vectors to the pocketlocation of the implanted electronics unit 102 of the CRM device 100 caninclude: (1) LV-Can-RA; or (2) RV-Can-RA. For a right side pectorallyimplanted electronics unit 102 of the CRM device 100, examples oforthogonal vectors to the pocket location of the implanted electronicsunit 102 of the CRM device 100 can include (1) RV-Can-RA; or (2)LV-Can-RA; or (3) LV-Can-RV.

In an example that includes a lead-connected or other pulmonary arterypressure (PAP) sensor that includes a pulmonary artery (PA) electrode,this provides more possibilities for providing orthogonal vectors, for aleft-side implanted electronics unit 102 or a right-side implantedelectronics unit 102, e.g., PA-Can-X, wherein X can include anintracardiac electrode, such as any of the intracardiac electrodesdescribed above.

In an example, for a left-side pectorally implanted electronics unit 102of the CRM device 100, examples of orthogonal vectors to the heart caninclude: (1) Can-RV-RA; or (2) Can-LV-RA. For a right side pectorallyimplanted electronics unit 102 of the CRM device 100, examples oforthogonal vectors to the heart can include (1) Can-RV-LV; or (2)Can-LV-RV (where LV can represent any one of the different electrodesthat are typically associated with the left ventricle).

ADDITIONAL NOTES

The above detailed description includes references to the accompanyingdrawings, which form a part of the detailed description. The drawingsshow, by way of illustration, specific embodiments in which theinvention can be practiced. These embodiments are also referred toherein as “examples.” Such examples can include elements in addition tothose shown or described. However, the present inventors alsocontemplate examples in which only those elements shown or described areprovided. Moreover, the present inventors also contemplate examplesusing any combination or permutation of those elements shown ordescribed (or one or more aspects thereof), either with respect to aparticular example (or one or more aspects thereof), or with respect toother examples (or one or more aspects thereof) shown or describedherein.

All publications, patents, and patent documents referred to in thisdocument are incorporated by reference herein in their entirety, asthough individually incorporated by reference. In the event ofinconsistent usages between this document and those documents soincorporated by reference, the usage in the incorporated reference(s)should be considered supplementary to that of this document; forirreconcilable inconsistencies, the usage in this document controls.

In this document, the terms “a” or “an” are used, as is common in patentdocuments, to include one or more than one, independent of any otherinstances or usages of “at least one” or “one or more.” In thisdocument, the term “or” is used to refer to a nonexclusive or, such that“A or B” includes “A but not B,” “B but not A,” and “A and B,” unlessotherwise indicated. In the appended claims, the terms “including” and“in which” are used as the plain-English equivalents of the respectiveterms “comprising” and “wherein.” Also, in the following claims, theterms “including” and “comprising” are open-ended, that is, a system,device, article, or process that includes elements in addition to thoselisted after such a term in a claim are still deemed to fall within thescope of that claim. Moreover, in the following claims, the terms“first,” “second,” and “third,” etc. are used merely as labels, and arenot intended to impose numerical requirements on their objects.

Method examples described herein can be machine or computer-implementedat least in part. Some examples can include a computer-readable mediumor machine-readable medium encoded with instructions operable toconfigure an electronic device to perform methods as described in theabove examples. An implementation of such methods can include code, suchas microcode, assembly language code, a higher-level language code, orthe like. Such code can include computer readable instructions forperforming various methods. The code may form portions of computerprogram products. Further, the code may be tangibly stored on one ormore volatile or non-volatile computer-readable media during executionor at other times. These computer-readable media may include, but arenot limited to, hard disks, removable magnetic disks, removable opticaldisks (e.g., compact disks and digital video disks), magnetic cassettes,memory cards or sticks, random access memories (RAMs), read onlymemories (ROMs), and the like.

The above description is intended to be illustrative, and notrestrictive. For example, the above-described examples (or one or moreaspects thereof) may be used in combination with each other. Otherembodiments can be used, such as by one of ordinary skill in the artupon reviewing the above description. The Abstract is provided to complywith 37 C.F.R. §1.72(b), to allow the reader to quickly ascertain thenature of the technical disclosure. It is submitted with theunderstanding that it will not be used to interpret or limit the scopeor meaning of the claims. Also, in the above Detailed Description,various features may be grouped together to streamline the disclosure.This should not be interpreted as intending that an unclaimed disclosedfeature is essential to any claim. Rather, inventive subject matter maylie in less than all features of a particular disclosed embodiment.Thus, the following claims are hereby incorporated into the DetailedDescription, with each claim standing on its own as a separateembodiment. The scope of the invention should be determined withreference to the appended claims, along with the full scope ofequivalents to which such claims are entitled.

1. (canceled)
 2. A system comprising: a tissue impedance measurementcircuit configured to sense a first tissue impedance measurement using afirst impedance measurement vector, and to sense a second tissueimpedance measurement using a different second impedance measurementvector, wherein: the first impedance measurement vector includes a firstexcitation vector for providing a first excitation signal, and a firstresponse vector for sensing a first response to the first excitationsignal, the first excitation vector being non-orthogonal to the firstresponse vector; and the second impedance measurement vector includes asecond excitation vector for providing a second excitation signal, and asecond response vector for sensing a second response to the secondexcitation signal, the second excitation vector being substantiallyorthogonal to the second response vector; a detector circuit,communicatively coupled to the tissue impedance measurement circuit,configured to generate an indication of fluid accumulation at a bodylocation using both the first and second impedance measurements.
 3. Thesystem of claim 2, wherein the indication of fluid accumulation includesan indication of fluid accumulation at a lung region, and the detectorcircuit is further configured to detect a heart failure decompensationevent using at least the indication of fluid accumulation.
 4. The systemof claim 2, wherein the detector circuit is configured to determine achange in the first tissue impedance measurement over a period of timeand a change in the second tissue impedance measurement over the periodof time, and to generate the indication of fluid accumulation using acomparison between the change in the first tissue impedance measurementand the change in the second tissue impedance measurement.
 5. The systemof claim 4, wherein the change in the first tissue impedance measurementincludes a fractional change from a baseline first tissue impedancemeasurement, and the change in the second tissue impedance measurementincludes a fractional change from a baseline second tissue impedancemeasurement.
 6. The system of claim 4, wherein the detector circuit isconfigured to generate the indication of fluid accumulation in responseto a relative indication between the change in the second tissueimpedance measurement and the change in the first tissue impedanceexceeding a specified threshold.
 7. The system of claim 4, wherein thedetector circuit is configured to compute a weighed combination of thechange in the first tissue impedance measurement and the change in thesecond tissue impedance measurement, and to generate the indication offluid accumulation in response to the weighted combination meeting aspecified criterion.
 8. The system of claim 2, wherein the secondimpedance measurement vector comprises: the second excitation vectorprovided between a left ventricular electrode configured to beassociated with a left ventricle and a pectoral electrode configured tobe associated with a pectoral region; and the second response vectorprovided between a left ventricular electrode configured to beassociated with the left ventricle and a right atrial electrodeconfigured to be associated with a right atrium.
 9. The system of claim2, wherein the second impedance measurement vector comprises: the secondexcitation vector provided between a right ventricular electrodeconfigured to be associated with a right ventricle and a pectoralelectrode configured to be associated with a pectoral region; and thesecond response vector provided between a right ventricular electrodeconfigured to be associated with the right ventricle and a right atrialelectrode configured to be associated with a right atrium.
 10. Thesystem of claim 2, wherein the second impedance measurement vectorcomprises: the second excitation vector provided between a pulmonaryartery electrode configured to be associated with a pulmonary artery anda pectoral electrode configured to be associated with a pectoral region;and the second response vector provided between a pulmonary arteryelectrode configured to be associated with the pulmonary artery and aright atrial electrode configured to be associated with a right atrium.11. The system of claim 2, wherein at least one of: the first impedancemeasurement vector comprises the first excitation vector providedbetween a right ventricular electrode configured to be associated with aright ventricle and a pectoral electrode configured to be associatedwith a pectoral region, and the first response vector provided between aright ventricular electrode configured to be associated with a rightventricle and a pectoral electrode configured to be associated with apectoral region; the first impedance measurement vector comprises thefirst excitation vector provided between a right atrial electrodeconfigured to be associated with a right atrium and a pectoral electrodeconfigured to be associated with a pectoral region, and the firstresponse vector provided between a right atrial electrode configured tobe associated with a right atrium and a pectoral electrode configured tobe associated with a pectoral region; or the first impedance measurementvector comprises the first excitation vector provided between a leftventricular electrode configured to be associated with a left ventricleand a pectoral electrode configured to be associated with a pectoralregion, and the first response vector provided between a leftventricular electrode configured to be associated with a left ventricleand a pectoral electrode configured to be associated with a pectoralregion.
 12. The system of claim 2, further comprising at least onetemperature sensor configured to sense temperature of at a bodylocation, wherein the detector is configured to generate the indicationof fluid accumulation further in response to the sensed temperaturefalling within a specified range.
 13. The system of claim 2, furthercomprising a therapy delivery circuit configured to deliver a therapyprogrammed using at least the indication of fluid accumulation.
 14. Amethod for assessing fluid status at a body location using a medicalapparatus, comprising: sensing a first tissue impedance measurement,including applying a first excitation signal to a first excitationvector, and sensing from a first response vector a first response to thefirst excitation signal, the first excitation vector beingnon-orthogonal to the first response vector; sensing a second tissueimpedance measurement, including applying a second excitation signal toa second excitation vector, and sensing from a second response vector asecond response to the second excitation signal, the second excitationvector being substantially orthogonal to the second response vector; andgenerating an indication of fluid accumulation at the body locationusing both the first and second impedance measurements.
 15. The methodof claim 14, further comprising detecting a heart failure decompensationevent using at least the indication of fluid accumulation, wherein theindication of fluid accumulation includes an indication of fluidaccumulation at a lung region.
 16. The method of claim 14, whereingenerating the indication of fluid accumulation includes determining achange in the first tissue impedance measurement over a period of timeand a change in the second tissue impedance measurement over the periodof time, and generating the indication of fluid accumulation using acomparison between the change in the first tissue impedance measurementand the change in the second tissue impedance measurement.
 17. Themethod of claim 14, wherein generating the indication of fluidaccumulation includes determining a relative indication between thechange in the second tissue impedance measurement and the change in thefirst tissue impedance, and generating the indication in response to therelative indication exceeding a specified threshold.
 18. The method ofclaim 14, wherein sensing the second tissue impedance measurementincludes applying the second excitation signal between a leftventricular electrode configured to be associated with a left ventricleand a pectoral electrode configured to be associated with a pectoralregion, and sensing the second response between a left ventricularelectrode configured to be associated with the left ventricle and aright atrial electrode configured to be associated with a right atrium.19. The method of claim 14, wherein sensing the second tissue impedancemeasurement includes applying the second excitation signal between apulmonary artery electrode configured to be associated with a pulmonaryartery and a pectoral electrode configured to be associated with apectoral region, and sensing the second response between a pulmonaryartery electrode configured to be associated with the pulmonary arteryand a right atrial electrode configured to be associated with a rightatrium.
 20. The method of claim 14, wherein sensing the first tissueimpedance measurement includes at least one of: applying the firstexcitation signal between a right ventricular electrode configured to beassociated with a right ventricle and a pectoral electrode configured tobe associated with a pectoral region, and sensing the first responsebetween a right ventricular electrode configured to be associated with aright ventricle and a pectoral electrode configured to be associatedwith a pectoral region; applying the first excitation signal between aright atrial electrode configured to be associated with a right atriumand a pectoral electrode configured to be associated with a pectoralregion, and sensing the first response between a right atrial electrodeconfigured to be associated with a right atrium and a pectoral electrodeconfigured to be associated with a pectoral region; or applying thefirst excitation signal between a left ventricular electrode configuredto be associated with a left ventricle and a pectoral electrodeconfigured to be associated with a pectoral region, and sensing thefirst response between a left ventricular electrode configured to beassociated with a left ventricle and a pectoral electrode configured tobe associated with a pectoral region.
 21. The method of claim 14,further comprising delivering a therapy according to at least onetherapy parameter, the at least one therapy parameter programmed usingat least the indication of fluid accumulation.